Disarmed

It is a warm and beautiful fall day. The Attack One crew is eating dinner when it's dispatched for a "motor vehicle accident with injury" on a small, quiet residential street. As they approach the accident, they first note only a parked construction truck with a few paint marks on it. Ahead is a small car, with no damage obvious to the rear or driver's side. But several bystanders are standing next to the passenger side of the vehicle, and a nearby police officer is placing a towel over something in the street.

   Approaching the vehicle on foot, the crew finds an entirely different scene. In the passenger seat is a young man in acute distress. His right arm has been amputated, and bystanders have covered it in a towel, and fashioned a tourniquet from a man's belt to control the bleeding. The entire passenger side of the car is filled with blood, and it is covering the side of the car. In the backseat is a young woman, who is groggy and has a lot of blood on her as well. An older man and one of the police officers who arrived before Attack One are sitting on a curb in front of the car; both have vomited. It is now clear what the other police officer has covered with a towel and is standing over: the young man's right arm.

   A man who identifies himself as the father of the young woman is able to explain the scene. His daughter and her boyfriend had just finished dinner with the family and were pulling out of the driveway at a low rate of speed. The young woman was driving, and didn't notice the construction truck parked just off the end of the driveway. She sideswiped the truck, and unfortunately her boyfriend in the passenger seat had his arm outside the window. The arm was torn off.

Hearing the screams of the young people, the family and some neighbors ran out to assist, and one of the neighbors thought to wrap the arm in a towel and try to control the bleeding. When direct pressure wouldn't work, another neighbor took off his belt and made it into a tourniquet.

The daughter is uninjured, but had passed out after trying to help, so they laid her in the backseat. Seeing the injury and blood, some neighbors also got ill, as did the first-arriving police officer.

   The Attack One paramedic assumes control of the right arm stump and tourniquet from the bystander, and does a quick assessment of the young man. He is in extreme pain, but can report that nothing else is injured. His airway is uncompromised, and he has no respiratory distress, with adequate perfusion and brisk capillary refill in the left hand. He has suffered significant bleeding from his amputated arm, and the paramedic notes large amounts of blood in the seat, on the floor, on the window, and down the outside of the car and into the street.

   The Attack One crew immediately requests another ambulance to assist with the other persons, and prepares the young man for transport. The paramedic attempts to look at the end of the stump to confirm the blunt type of amputation, and notes there is a jagged edge, with parts of exposed muscle, blood vessels and other tissue. There is active bleeding from the stump when the belt slips, so the paramedic replaces the belt with a blood pressure cuff inflated to about 150 mmHg and clamped. This provides a more comfortable way to keep a tourniquet in place.

   The crew slips the patient out of the car. Because his clothing is so bloody, they leave it in the car and place him in a sheet. They quickly start a large-bore IV line in the left arm and administer morphine. They place the amputated arm in the ambulance with the patient. It is supported on a long arm board, with dressings loosely applied to the skin surface and a small amount of saline used to dampen the dressings. The other incoming fire and EMS crews will evaluate and manage the young lady and bystanders.

   Attack One transports the patient to a regional hospital with an active hand surgery service. En route, the crew attempts pain control with morphine, but the patient experiences pain throughout the transport at the site of the tourniquet. He remains conscious during transport, receiving fluid resuscitation with two liters of saline, and his overall perfusion status improves.

Hospital Course

   On arrival in the ED, the patient is greeted by the trauma team. The injury is limited to the amputated arm. The bones and muscles have been crushed, and most of the skin torn and damaged. There is also significant damage to the ends of the blood vessels. As the patient is wheeled out of the emergency department to the operating room, the surgeons explain that there is little chance the arm can be replanted. In response to a question from the Attack One crew, the patient had said he is left-handed, which provides a small glimmer of good news: Even if the right arm can't be saved, the patient will have his dominant hand still functional.

   As the patient is being wheeled out, he asks to speak to the Attack One members. He wants to make sure the crew knows how grateful he is for their care, and asks if they will pass on his thanks to the bystanders who assisted him and "saved his life." The crew assures the patient they'll pass on his message, and that everyone will be hoping for his recovery. Then the crew returns to the scene, where they find many of the neighbors, police officers and bystanders still there. An engine crew is assisting in the cleanup of the vehicles and roadway.

   To fulfill the patient's request, the Attack One crew leader calls everyone together and conveys the message of gratitude, particularly recognizing those who participated in the lifesaving first aid. While delivering this news, the crew members note the continued discomfort of many bystanders, so they ask for the fire-EMS chaplain to report to the scene to provide some immediate debriefing and counseling. The crew briefs the chaplain on the nature of the emergency and critical work of bystanders, and the chaplain ultimately provides significant relief to the distraught neighbors and police officers. Since the young lady and both families are well-acquainted, patient follow-up can be provided through them. That will help close the loop and allow everyone to know how much their efforts contributed to the patient's outcome.

   Back at the hospital, the patient is stabilized in the operating room, but surgeons find there is no hope of replanting the arm. They complete an upper arm amputation and skin grafting to cover the end of the stump. The patient enters a long rehabilitation period.

Case Discussion

   Motor vehicle accidents can produce an infinite number of injuries. Even low-speed crashes can produce devastating harm. Bodies and body parts caught between multiton vehicles, even at coasting speeds, will sustain significant damage.

   Blunt amputations produce injuries to bones, soft tissue, blood vessels and nerves that are not predictable. Many of these injuries do not actively bleed. A crushing force can damage deep compartments of the extremity, including the blood vessels and nerves, and result in almost immediate clamp-down of the big blood vessels. In other cases of blunt extremity injury, both arteries and veins can be sheared off in irregular ways, and bleeding can be very difficult to control. This has become a challenge for our military emergency care personnel, because these types of injuries are common on the modern battlefield. Across the globe, military rescuers have widely adopted the use of tourniquets to control bleeding, especially when scenes are not safe and rapid evacuation will reduce the risk to both victims and rescuers.

   A tourniquet is a tightly tied band applied around a body part (arm or leg). There are a variety of types, from the crude "cravat and stick" to Velcro bands to portable devices produced from components of blood pressure cuffs. The modern devices, with a wider band and predictable pressure, produce much less pain for the patient. Some EMS systems have placed portable pneumatic tourniquets in service as a first-line treatment for life-threatening extremity hemorrhage.

   The United States military has begun to publish its recent experience with the use of tourniquets, and the results are positive.1 Prior literature has already advocated for EMS use of tourniquets for civilian injuries,² but last three years have seen the publication of studies that confirm their utility. The author members of the 31st Combat Support Hospital Research Group, led by Dr. Alec Beekley, have summarized the results of their work:¹

   "Prehospital tourniquet use is an effective means of establishing extremity hemorrhage control in military casualties. Tourniquet use is associated with low risk of ischemia-related complications or neurologic injury."

   "Liberalized use of prehospital tourniquets as a first-line treatment for extremity hemorrhage should continue."

   "Prehospital providers and treating surgeons should be cognizant of the possibility of failure of the tourniquet to control hemorrhage, particularly at the above-knee level."

   "To avoid rebleeding or bleeding through a prehospital tourniquet, hospital physicians should replace those tourniquets with pneumatic tourniquets as soon as possible after patient arrival to the medical center."

   In the civilian trauma population, tourniquet use has been viewed cautiously. Civilian injuries occur in a wide population range—not the young, healthy population of military personnel. Most trauma injuries have bleeding that is easy to control with direct pressure. First aid classes have historically contained a section on tourniquet use, and it is common for EMS providers to remove tourniquets placed by members of the public on extremities that have relatively minor injuries. But there are certain extremity injuries that produce rapid bleeding that will be difficult for EMS providers to control, and a tourniquet is an excellent tool to utilize for a short time.

   Applying a tourniquet causes pain in the conscious patient. More pain occurs when the tourniquet band is thin or places uneven pressure. Pain control is beneficial in the conscious patient, especially one who has a major injury isolated to the single extremity and no distracting factors. Pain control for EMS providers typically is provided through narcotic medications. Medical control may be helpful in directing pain control medications in the patient with multiple injuries and when the patient is perfusing poorly. Early contact will allow the hospital to mobilize trauma resources and any equipment needed for immediate care on arrival.

Initial Assessment

   An 18-year-old male in acute distress. His arm has been amputated in a very irregular fashion. Bystanders have fashioned a trouniquet to control bleeding.

• Airway: Uncompromised.
  Breathing: No respiratory distress
• Circulation: Adequate perfusion, brisk capillary refill. Significant bleeding from the amputated arm.
• Disability: Patient reports severe pain in the arm.
  Exposure of Other Major Problems:
  The young man's girlfriend is extremely upset, as are a number of bystanders.

Vital Signs

Ample Assessment

• Allergies: None
• Medications: None
• Past Medical History: No significant medical problems
• Last Intake: Just prior to the accident
• Event: A low-speed auto accident results in a traumatic amputation of a victim's arm

Customer Service Opportunity

   This incident brought a range of bystanders to assist a severely injured patient with an unusual injury. The bystanders performed a critical intervention and worked with law enforcement to provide as much care as possible prior to EMS arrival. There are situations where bystanders make a significant investment in the care of victims, and will benefit from feedback on how well they performed and victims' outcomes. Considering the significant privacy protections owed to EMS patients, there are still ways for EMS personnel to assist in connecting rescuers to victims. In this situation, "family knows family," so there was an easy way to establish a communications bridge.

   There are also incidents where bystanders will be overwhelmed by the sights, sounds and/or smells of the emergency. This incident had essentially all of those elements, and brought enough distress to the witnesses, rescuers and even law enforcement to cause a multiple-casualty incident. In the midst of providing critical patient care, it is important for EMS crew leaders to be prepared to mitigate the effects on other witnesses, so they don't also become victims.

Learning Point

Unexpected amputation and use of tourniquets. In certain victims with particular injuries to extremities, tourniquets may be lifesaving.

References

   1. Beekley AC, Sebesta JA, et al. Prehospital tourniquet use in Operation Iraqi Freedom: Effect on hemorrhage control and outcomes. J Trauma 64: S28–S37, 2008.

   2. Husum H, Gilbert M, Wisborg T, Pillgram-Larsen J. Prehospital tourniquets: There should be no controversy. J Trauma 56: 214–215, 2004.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. Contact him at jaugustine@emp.com.